Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, Calif; Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif; Department of Surgery, University of California San Francisco - East Bay, Oakland, Calif.
Stanford-Surgery Policy Improvement Research & Education Center, Stanford University, Stanford, Calif; Division of Vascular Surgery, Stanford University School of Medicine, Stanford, Calif.
J Vasc Surg. 2020 Nov;72(5):1735-1742.e3. doi: 10.1016/j.jvs.2020.01.043. Epub 2020 Mar 10.
The role of carotid endarterectomy (CEA) continues to be debated in the age of optimal medical therapy, particularly for patients with limited life expectancy. The Risk Analysis Index (RAI) measures frailty, a syndrome of decreased physiologic reserve, which increases vulnerability to adverse outcomes. The RAI better predicts surgical complications, nonhome discharge, and death than age or comorbidities alone. We sought to measure the association of frailty, as measured by the RAI, with postoperative in-hospital stroke, long-term stroke, and long-term survival after CEA. We also sought to determine how postoperative stroke interacts with frailty to alter survival trajectory after CEA.
We queried the Vascular Quality Initiative CEA procedure and long-term data sets (2003-2017) for elective CEAs with complete RAI case information. For all analyses, the cohort was divided into asymptomatic and symptomatic carotid stenosis. Scoring was defined as not frail (RAI <30), frail (RAI 30-34), and very frail (RAI ≥35). Mortality information through December 2017 was obtained from the Social Security Death Index. Multivariable models (logistic and Cox proportional hazards regressions) were used to study the association of frail and very frail patients with the outcomes of interest. In a post hoc analysis, we created Kaplan-Meier curves to analyze patient mortality after CEA as well as after postoperative stroke.
Of the 42,869 included patients, 17,092 (39.9%) were female, and 38,395 (89.6%) were white. There were 25,673 (59.9%) patients assigned to the asymptomatic stenosis group and 17,196 (40.1%) patients in the symptomatic stenosis group. Frailty was not associated with perioperative or long-term postoperative stroke. The risk of long-term mortality was significantly higher for frail (hazard ratio, 1.9 [1.7-2.3]) and very frail (hazard ratio, 3.1 [2.6-3.7]) asymptomatic patients; symptomatic frail and very frail patients also had a two to three times increased risk of long-term mortality. Frail and very frail patients had two to three times the risk for long-term mortality compared with patients who were not frail. Postoperative stroke negatively affected the mortality trajectory for all patients in the cohort, regardless of frailty status.
RAI score is not associated with postoperative stroke; however, frail and very frail status is associated with decreased long-term survival in an incremental fashion based on increasing RAI. RAI assessment should be considered in the preoperative decision-making for patients undergoing CEA to ensure long-term survival and optimal surgical outcomes vs medical management.
在最佳药物治疗时代，颈动脉内膜切除术（CEA）的作用仍存在争议，尤其是对于预期寿命有限的患者。风险分析指数（RAI）衡量虚弱，即生理储备减少的综合征，这增加了对不良后果的脆弱性。RAI 比年龄或合并症更能准确预测手术并发症、非家庭出院和死亡。我们试图衡量虚弱（通过 RAI 测量）与 CEA 术后院内卒中、长期卒中以及 CEA 后长期生存之间的关联。我们还试图确定术后卒中如何与虚弱相互作用，以改变 CEA 后的生存轨迹。
我们在 2003-2017 年期间，从血管质量倡议（Vascular Quality Initiative）CEA 程序和长期数据集中查询了接受过完整 RAI 病例信息的选择性 CEA。在所有分析中，队列分为无症状和有症状颈动脉狭窄。评分定义为非虚弱（RAI<30）、虚弱（RAI 30-34）和非常虚弱（RAI≥35）。截至 2017 年 12 月的死亡率信息通过社会保障死亡指数获得。多变量模型（逻辑和 Cox 比例风险回归）用于研究虚弱和非常虚弱患者与感兴趣结果之间的关联。在事后分析中，我们创建了 Kaplan-Meier 曲线来分析 CEA 术后以及术后卒中后的患者死亡率。
在纳入的 42869 名患者中，17092 名（39.9%）为女性，38395 名（89.6%）为白人。25673 名（59.9%）患者被分配到无症状狭窄组，17196 名（40.1%）患者被分配到有症状狭窄组。虚弱与围手术期或长期术后卒中无关。无症状虚弱（危险比，1.9[1.7-2.3]）和非常虚弱（危险比，3.1[2.6-3.7]）患者的长期死亡率风险显著更高；有症状虚弱和非常虚弱患者的长期死亡率风险也增加了两倍至三倍。与非虚弱患者相比，虚弱和非常虚弱患者的长期死亡率风险增加了两倍至三倍。术后卒中对队列中所有患者的死亡率轨迹都有负面影响，无论虚弱状态如何。
RAI 评分与术后卒中无关；然而，虚弱和非常虚弱状态与 RAI 逐渐增加的情况下，长期生存率呈递减趋势。RAI 评估应在接受 CEA 的患者的术前决策中考虑，以确保长期生存和最佳手术结果，而非药物治疗。
